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January 15, 2008 Upcoming Deadlines for Performance Measurements and Public Accountability
Before discussing more deadlines, you all should be proud of the effort and commitment your hospital staffs have demonstrated in meeting all the new reporting requirements and deadlines in 2007. Especially challenging were the new shortened administrative timelines for hospital inpatient and outpatient surgery that began with patient discharges and outpatient cases in last half 2007. However, the most challenging timeline was the reporting of SCIP infection data for 3rd Quarter 2007 under the Hospital Report Card Act rules. This was the first quarter of reported data for SCIP infections for Inpatient PPS hospitals (and many Critical Access Hospitals voluntarily participated) --- at least 30 days ahead of the Joint Commission’s deadline and 45 days ahead of the Medicare Hospital Quality Alliance deadline for the same quarter. All Illinois hospitals should be commended for their commitment to this initiative as even with the holidays upon them, they all made the required reporting deadline of January 1st --- this was a major accomplishment given it was the first quarter for reporting this information to the Illinois Department of Public Health. Hospital Outpatient Quality Data Reporting Program Commitment Due January 31 Click here to obtain the form. You must complete the form and send it to the Florida Medicare QIO (FMQAI) who will be overseeing this initiative for the nation. Their mailing address is: HOP QDRP SC Please note that the mailing address is not on the form and the only way to submit is to send through the mail. IHA urges providers to send via a secure delivery and keep the tracking information in case the receipt of your hospital’s participation form is ever questioned. Measurements and Reporting Please keep in mind that the hospital outpatient measurements are focused on 5 heart attack measurements and 2 Surgical Care Improvement Program (SCIP) measurements. While the measurement specifications are practically the same as the inpatient, it is important to capture and identify the outpatient measurements possibly in different settings within your hospital. Critical Access Hospitals Cannot Submit HOP Measurements Per CMS Medicare Illinois Critical Access Hospitals (CAH) have raised concerns as to their current exclusion for reporting these measurements as the measurements to be utilized are more reflective of Critical Access Hospital care, especially for stabilization and transfers of heart attack patients. Illinois CAH providers would like to participate in this measurement initiative as it demonstrates the quality of services provided to patients suffering a heart attack that need to be stabilized and then transferred. IHA, along with several other state hospital associations and the American Hospital Association have expressed their concerns to CMS officials. While CMS has not issued a response yet, it is under discussion and IHA hopes to have feedback soon from CMS. HCAHPS Hospital Review Period – January 17 to February 15 The first set of HCAHPS publicly available information will include patient discharge responses from October 2006 through June 2007. Hospitals will have information presented on themselves in tabular and graphic form with comparisons available to other hospitals, state, and the nation. Hospitals should use this time to share these results with hospital boards, medical and clinical staff leadership, and hospital employees. As this information will be made public and it is much easier to understand than complicated clinical measurements, the public may find this information to be easier to understand and utilize for decision-making. Hospitals may also want to compare their results to more current information they may have already and to start charting their improvement processes and programs. In some preliminary results provided from the HCAHPS pilot, most hospitals across the nation had lower satisfaction scores in discharge planning and patient communications. While several hospitals scored low in these areas, there were also some hospitals across the nation that performed quite well in these areas. Regardless of where your performance is in the first set of public HCAHPS reports, it is important to identify ways to improve your hospital’s performance and the satisfaction of the patients and the families your hospital serves. State of Illinois Public Reporting If you have additional questions, please contact Pat Merryweather at pmerryweather@ihastaff.org. Thank you and please extend a special thank you to your staff as they have demonstrated such strong commitment and support to performance improvement and public accountability. | |||||||||||||
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